腰椎终板Modic改变与腰椎间盘突出的相关性研究

[目的]探讨腰椎终板Modic改变与腰椎间盘突出的相关性及其意义.[方法]对628例患者(年龄14～85岁,平均50岁;男326例,女302例)腰椎MRI上L3、4～L5S1节段的Modic改变和腰椎间盘突出程度进行评估,统计两者的相关性.将单节段中、重度腰椎间盘突出者分为A组(仅该节段有Modic改变)和B组(任一节段均无Modic改变).统计两组下腰痛的发生率并采用疼痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数评分(oswestry disability index,ODI)来评估腰痛程度.[结果]在1844个腰椎间盘中,椎间盘无突出组、轻度突出组、中度突出组和重度突出组Modic改变的发生率分别为6.83％、23.66％、42.72％和50.79％,差异有统计学意义(P＜0.01),Spearman相关检验表明Modic改变和腰椎间盘突出程度呈正相关(r=0.344,P＜0.01).A、B组下腰痛的发生率分别为59.32％和37.97％,差异有统计学意义(P＜0.01),但腰痛VAS评分和ODI评分差异无统计学意义(P＞0.05).[结论]腰椎终板Modic改变的发生与腰椎间盘突出程度呈正相关,当腰椎间盘突出合并Modic 改变特别是Ⅰ型改变时,下腰痛的发生率增加.     

腰椎间盘MRI高信号区的组织病理学特点和临床意义

目的研究椎间盘源性下腰痛患者腰椎间盘纤维环后方MRI高信号区的组织病理学特征及其临床意义。方法对52例经保守治疗无效、CT片显示无腰椎间盘突出的下腰痛患者行腰椎MR检查及腰椎间盘造影术。男39例,女13例;平均年龄38.8岁。选择纤维环后方出现高信号区的部分病例行腰椎后路椎间盘切除、椎体间融合、椎弓根螺钉内固定术,术中收集包括高信号区部位的椎间盘。对标本行矢状面连续组织学切片,光镜下观察高信号区椎间盘组织的组织病理学结构,并分析其临床意义。结果在行腰椎间盘造影的52例142个椎间盘中,17例17个椎间盘显示高信号区,且在椎间盘造影过程中全部呈现2或3级的纤维环破裂和疼痛复制反应。敏感性和特异性均为100%。高信号区与纤维环破裂程度分级呈正相关,说明纤维环破裂程度分级越高,越易出现高信号区(R=0.462,P<0.01)。共收集11例患者11个椎间盘,组织学研究发现对应高信号区的椎间盘组织表现为沿纤维环裂隙形成的不同程度的血管化肉芽组织,有成熟的瘢痕化胶原组织。结论症状性下腰痛患者的腰椎MRI上有椎间盘高信号区,可以作为椎间盘源性下腰痛诊断的重要征象。     

人工腰椎间盘置换术的并发症及其防治

目的:探讨人工腰椎间盘置换术并发症的原因及防治方法。方法:1999年12月~2001年11月间,应用Link(r)SBCharitéⅢ型人工椎间盘假体对30例患者的33个椎间盘进行了置换术,男16例,女14例;年龄36~54岁,平均44岁。腰椎间盘突出症22例,腰椎间盘切除术后失败6例,腰椎间盘退行性变2例。统计并发症发生的例数,分析其发生原因并探讨预防处理方法。结果:随访4个月~2年3个月,平均16.7个月。共发生7例20例次并发症,术中并发症包括腹膜撕裂3例次,椎前静脉出血1例次,椎体后上缘骨折1例次,假体位置不良4例次;术后并发症包括切口裂开1例次,腹膜后血肿1例次,腹壁切口疝1例次,6个椎间盘假体无运动,关节突关节自发性骨融合1例次,术后16个月椎弓根断裂1例次。结论:人工椎间盘置换术虽可保留手术节段的运动功能,但存在其特有的并发症,应严格手术适应证、掌握手术操作原则及技术并完善围手术期处理,减少并发症的发生。     

Validation of the intervertebral disc histological degeneration score in cervical intervertebral discs and their end plates

Background Context

Vertebral joints consist of intervertebral discs (IVDs) and cartilaginous end plates (EP) that lie superiorly and inferiorly to the IVDs and separate them from the adjacent vertebral bodies. With aging, both IVDs and EPs undergo degeneration. The Histologic Degeneration Score (HDS) is a grading system that microscopically evaluates the degree of degeneration in lumbar discs and predicts it with high accuracy basing on several histological markers of IVD and EP. There is currently a lack of validated histologic grading schemes for cervical spine degeneration.

腰椎间盘突出症的误诊误治分析

1例误诊误治的腰椎间盘突出症患者,经胶原酶溶盘术后,疼痛加重.术后腰椎MRI示:“L3椎体以下水平椎管内见异常信号影填充,呈椎管内铸型样变.终丝马尾神经未见”,转入神经外科手术.术中可见病变位于L3～S1椎管髓外硬膜下,表面光滑,且与一支神经根相连,术后病理诊断:“神经鞘瘤并坏死”.通过分析该病例误诊误治的原因,提示:忽视临床症状和体征的重要性,忽视症状体征和影像学检查结果的吻合,对腰椎间盘突出症及其他腰腿痛疾病缺乏足够的认识是造成腰椎间盘突出症误诊误治的主要原因.     

腰痛患者MRI上各节段腰椎间盘退变形式与年龄的相关性分析

目的:探讨腰痛患者MRI上各节段腰椎间盘退变形式与年龄的相关性.方法:回顾性分析2004-2006年共529例就诊于加州大学洛杉矶分校Santa Moniea骨科医院脊柱外科中心的腰痛伴或不伴有腿痛患者(男191例,女338例)的腰椎MRI资料,根据患者年龄分为5组,≤29岁、30～39岁、40～49岁、50～59岁及≥60岁组.按Pfirrmann's分级系统对每例患者腰椎各节段的椎间盘(LI/2～L5/S1)退变程度进行分级,所得数据采用SPSS 13.0进行统计学分析,总结其退变模式.结果:71例(13.4%)患者LI/2～L5/Si椎间盘退变程度表现为1-1-1-1-1,为正常椎间盘,是所有组合中最常见的.低年龄组发生严重退变(4级)的几率最低,L1/2、L2/3、L3,4椎间盘退变程度较IA/5、L5/S1低;1-1-1-1-1的发生率随着年龄的增加而明显降低,而1-1-1-1-2和1-1-1-1-3与之相反,发生率随着年龄的增加而明显升高.40岁以前,1-1-1-1-1的发生率最高;在40～49岁年龄组中.1-1-1-1-3的发生几率最高,为7.6%,而超过50岁,3-3-3-3-3发生的几率最高.单节段退变发生率与年龄呈负相关(P<0.01).随着年龄的增大而降低;而所有节段退变的发生率与年龄呈正相关(P(<0.01),随着年龄的增大而增加.结论:在腰痛患者中,腰椎单一节段退变所占比例随年龄增大而减小,而所有节段退变所占比例随年龄增大而增大.     

椎间盘镜治疗中央型腰间盘突出症附38例临床报告

腰椎间盘突出症是骨科常见病、多发病,其发病率日趋增高,治疗中央型间盘突出以手术为主,传统术式是全椎板切除,经硬膜囊内(或牵开硬膜囊)摘除突出变性的间盘组织,手术破坏了脊柱后柱,增加了脊柱的不稳定性,以致后期腰椎不稳,再次出现腰腿疼症状.随着微创技术引入脊柱外科,椎间盘镜下髓核摘除术的应用避免了后期脊柱不稳的发生,我院2001年初开展此技术,治疗中央型间盘突出38例,取得满意效果,初步报告如下.……     

MRI上腰椎间盘局限性高信号区与性别、年龄、体重及腰痛症状的相关性研究

目的：探讨MRI上腰椎间盘局限性高信号区（HIZ）与性别、年龄、体重及腰痛症状的相互关系。方法：回顾性分析572例（2860个椎间盘）腰椎MRI资料中HIZ发生率与性别、年龄、体重和腰痛症状的相互关系。对16个发生HIZ的腰椎间盘行CT椎间盘造影（CTD）,对所得图像行改良Dallas分级并结合疼痛诱发试验综合分析。结果：HIZ发生率为34.97%（200例）,男性为34.46%,女性为35.63%,性别间差异无统计学意义（P〉0.05）。18岁后,HIZ发生率随年龄增长逐渐升高,50～59岁达到高峰（56.70%）,此后发生率逐步降低。体重增加亦可致HIZ发生率升高,当体重≥90kg时,HIZ发生率达57.89%。腰痛者HIZ发生率（42.75%）高于无腰痛者（28.05%）,二者存在显著性差异（P〈0.001）。16个行CTD的椎间盘中,疼痛诱发试验阳性者多为Dallas 4级（8/9）,疼痛诱发试验阴性者多为Dallas 3级（6,7）。结论：MRI上腰椎间盘HIZ与年龄、体重及腰痛症状相关。     

The effect of posterior spinal fixation with acrylic cement on the vertebral growth plate and intervertebral disc in dogs

Summary We have attempted to clarify the serial histological changes in the growing spine of dogs following posterior fixation with acrylic cement. Twenty-four male mongrel dogs aged 8 weeks were used for the study. The lumbar spine from L.3 to L.5 was fixed posteriorly with acrylic cement. Three dogs were then sacrificed every four weeks up to 32 weeks, and the histological changes of the vertebral disc, growth plate and vertebral bodies were observed by light microscopy.Thinning of the growth plate and distortion of the cartilage columns has been demonstrated, but premature fusion of the growth plate did not result and vertebral body growth continued. Anterior wedging of the intervertebral disc was seen with some thinning of the bony trabeculae of the vertebral body.Degeneration of the nucleus pulposus resulted, with replacement by fibrous tissue. The normal horizontal arrangement of the fibres of the annulus fibrosus altered to a vertical configuration by 32 weeks.

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Résumé Les auteurs ont cherché préciser les modifications histologiques qui surviennent au niveau du rachis chez le chien période de croissance après fixation postérieure à l'aide de ciment acrylique. Ils ont utilisé pour ce travail 24 chiens bâtards âgés de 8 semaines. La colonne lombaire a été fixée de L3 à L5 avec du ciment. Trois chiens ont été sacrifiés toutes les quatre semaines jusqu'à la 32ème semaine et les modifications histologiques du disque, de la plaque de croissance et du corps vertébral ont été étudiées microscopiquement.On a mis en évidence un amincissement de la plaque de croissance avec incurvation des colonnes cartilagineuses, mais sans soudure prématurée du cartilage de conjugaison, donc avec poursuite de la croissance du corps vertébral. On a observé un pincement antérieur du disque et un amincissement des travées au niveau des corps vertébraux.Il en est résulté une dégénérescence du nucleus pulposus qui est remplacé par du tissu fibreux. La disposition normale horizontale des fibres de l'annulus se verticalise à la 13ème semaine.

     

High-intensity zone (HIZ) of lumbar intervertebral disc on T2-weighted magnetic resonance images: spatial distribution, and correlation of distribution with low back pain (LBP)

Objectives

To analyze the three-dimensional distribution of high-intensity zone (HIZ) in lumbar disks and to assess the correlation between low back pain (LBP) and spatial distribution of HIZs.

Methods

Clinical records and lumbar MRIs of 623 patients (337 males and 286 females, age 50.10 ± 15.38 years) were selected and reviewed. Baseline characteristics and 3D localization were performed and recorded by two radiologists in a blind fashion.

Results

Among the 623 patients, 200 exhibited an HIZ in at least one disk. HIZs were more frequently seen in the inferior part of annulus fibrosus (superior–middle–inferior ratio 39:59:140, P < 0.001). One hundred and eighty-one HIZs (76.1%) occurred at L4/5 and/or L5/S1. The prevalence of multi-segmental HIZ was 16.5%. Among the 33 patients with multi-segmental HIZs, 24 exhibited HIZs in adjacent disks. The LBP rate of HIZ patients was significantly higher than that of patients who exhibited no HIZ (57.5 vs. 47.8%, P < 0.05). There was no evidence for a correlation between LBP and spatial distribution of HIZ in disk (P > 0.05). The incidence of LBP was slightly higher when the HIZ disk level was lower or when there were HIZs exhibited in more disks; however, the difference was statistically insignificant (P > 0.05).

Conclusions

High-intensity zones occurred frequently at lower segments, inferior part of annulus fibrosus, and single disk.     

Reasons for failure of L5-S1 intervertebral disc excisions

Summary This study reviews 247 patients who still had preoperative complaints six months to two years after disc excision. In over half, spondylosis of the L5-S1 facets was present, concurrently associated with a pelvic obliquity. A number of other organic causitive factors were identified in 18% of the patients. Nonorganic reasons accounted for failure in only 13%. Over 70% of patients with associated spondylosis were improved by treatment directed at this condition.

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Résumé Cette étude concerne 247 patients qui continuaient à souffrir six mois à deux ans après ablation d'une hernie discale. Plus de la moitié d'entre eux présentaient une arthrose des articulations intervertébrales postérieures L5-S1, habituellement associée à une obliquité du bassin. D'autres causes organiques furent mises en évidence chez 18% des patients. L'échec n'était dû à une cause inorganique que dans 13% des cas. Plus de 70% des patients présentant une arthrose des articulaires postérieures furent améliorés par le traitement de cette affection.

     

基于疼痛特点的腰椎间盘突出症个体化疾病诊断

疼痛是所有腰腿痛病例共同的临床症状,但疼痛的病因、病理、部位（范围或区域）、强度、性质、演变情况和影响因素等具有一定的特点与规律。这些个体化差异既是特定疾病临床诊断的首要依据,也是鉴别诊断的重要参考。在明确疾病诊断与鉴别诊断的基础上,腰椎间盘突出症病例尚须进一步区别典型与非典型、单纯与复合、普通与特殊等个体化疾病特征,在此基础上才能确定个体化疾病治疗方案。     

胶原酶髓核溶解术治疗腰椎间盘突出症概述

胶原酶髓核溶解术是治疗腰椎间盘突出症的一种有限手术,将胶原酶注入突出的椎间盘中或突出髓核周围,通过该酶催化降解髓核的胶原成分,降低髓核内的压力,使突出的椎间盘缩小或回复,减轻或解除对神经根的压迫,达到缓解或消除症状的目的.该方法是介于保守治疗与外科手术之间的方法,1968年哈佛大学医学院Sussman[1]首先提出用胶原酶替代木瓜凝乳蛋白酶溶解突出椎间盘,随后有更多的学者致力于该方法的研究.本文对胶原酶髓核溶解术治疗腰椎间盘突出症的实验与临床研究进展综述如下.……     

腰椎间盘内破裂的诊断和治疗

目的　研究腰椎间盘内破裂的诊断和治疗方法。　方法　 36例慢性失能性下腰痛病人 ,经腰椎间盘造影术证实为腰椎间盘内破裂 ,选择腰椎体间融合术 ,其中 8例行后路椎体间植骨融合椎弓根螺钉系统内固定术 (PLIF) ,2 8例行前路髓核摘除植骨融合术 (ALIF)。分别于术前、术后对病人的腰痛情况进行视觉疼痛自我评定尺 (VAS)评分 ,同时评估术后腰椎融合率。　结果　术后随访时间 6～ 2 6个月 ,平均 18个月。 8例行PLIF者 ,6例术后腰腿痛症状基本消失 ,2例仍有轻度腰痛 ,术前、术后VAS腰痛评分 ,差异有非常显著性意义 (P <0 0 1)。 2 8例行ALIF者 ,2 7例腰腿痛症状基本消失 ,术前、术后VAS腰痛评分 ,有非常显著性差异 (P <0 0 1)。行PLIF患者 ,融合率为 88% ,行ALIF者 ,融合率达 97%。　结论　腰椎椎体间融合术是治疗腰椎间盘内破裂的有效方法 ,但应严掌握手术适应证     

Modic changes following lumbar disc herniation

Only a small proportion (20%) of patients with LBP can be diagnosed based on a patho-anatomical entity. Therefore, the identification of relevant subgroups, preferably on a patoanatomical basis, is strongly needed. Modic changes have been described by several authors as being closely linked with LBP. The aims of this study were to describe the prevalence of Modic changes, their development as well as their association to LBP, previous disc contour, and surgery in patients with previous severe sciatica. This is a longitudinal cohort study where the patients were recruited from an RCT comparing two active conservative treatments, the 181 patients, who at baseline had radicular pain in or below the knee; all underwent a physical examination and MRI. MRI’s, pain history and physical examination of 166 patients were obtained at follow-up 14 months later. The prevalence of Modic changes type 1 increased from 9% at baseline to 29% at follow-up. At that time, a strong association between Modic changes and non-specific LBP was noted. Apparently, Modic changes type 1 was more strongly associated with non-specific lumbar pain than Modic changes type 2. The development of new Modic changes was closely related to the level of a previous disc herniation. A lumbar disc herniation is a strong risk factor for developing Modic changes (especially type 1) during the following year. Furthermore, Modic changes are strongly associated with LBP.     

Histologic findings of disc, end plate and neural elements after coblation of nucleus pulposus: an experimental nucleoplasty study

BACKGROUND CONTEXT: Partial removal of the nucleus has been shown to decompress herniated discs, relieving pressure on nerve roots and, in some cases, offering relief from disc pain. The nucleoplasty technique builds on earlier surgical approaches that helped validate the strategy of intranuclear tissue removal. Nucleoplasty, a new minimally invasive procedure using patented coblation technology, combines coagulation and ablation for partial removal of the nucleus pulposus to decompress the disc. PURPOSE: To determine if histologic changes of the intervertebral discs and surrounding tissues occur after nucleoplasty. STUDY DESIGN: A light microscopic study of intervertebral disc and adjacent neural tissues after disc decompression by nucleoplasty in pig cadavers. METHODS: Light microscopy was used to examine disc and neural tissues in two pig cadaveric specimens (T12 to sacrum). Nucleoplasty was performed by 1) advancing a radiofrequency wand to a predetermined depth in the disc (ablation), and 2) withdrawing the wand to the starting point (coagulation). Discs and adjacent tissues were removed from treated and nontreated segments, and examined under light microscopy. RESULTS: Histologic examination revealed no evidence of direct mechanical or thermal damage to the surrounding tissues. There was clear evidence of coblation channels with clean coagulation borders of the nucleus pulposus. Normal histologic findings of the annulus and end plate, with normal neural elements of the spinal cord and nerve roots at the level of the procedure, were observed. CONCLUSIONS: The histologic findings of this study suggest that the nucleoplasty achieves volumetric removal of target disc tissue without overt thermal or structural damage to the adjacent tissues. Further studies in live animals will be needed to assess the effects of nucleoplasty on the annulus, end plate and neural tissues under physiologic conditions, including assessment of cell viability.     

An analysis of radiating pain at lumbar discography

This study aimed to identify the morphological abnormalities of the intervertebral disc, as demonstrated by lumbar discography, that are associated with pain radiation to the hip, groin, buttock or lower limb. We carried out a retrospective review of 99 consecutive lumbar discogram reports. The association of disc degeneration, annular tears (partial or full thickness) and the level of disc injected was determined with respect to the presence and pattern of radiating pain. A total of 260 discs were injected, of which 179 were considered abnormal. Posterior annular tears were demonstrated in 84 discs, anterior annular tears in 15 discs and 45 discs had both anterior and posterior tears. A significant association was identified between isolated posterior tears and the production of concordant radiating pain (P = 0.0041). No difference was identified between partial thickness posterior tears and full thickness posterior tears associated with leak of contrast medium, with regard to radiating pain. Similarly, there was no significant association between disc level injected and the pattern of pain radiation. The results indicate that pain experienced in the buttock, hip, groin or lower limb can arise from the posterior annulus of the intervertebral disc without direct involvement of the nerve root. Received: 29 November 1997 Revised: 20 March 1998 Accepted: 6 April 1998     

Posterior and anterior epidural and intradural migration of the sequestered intervertebral disc: Three cases and review of the literature

Context: Dorsal migration of the sequestered lumbar intervertebral disc is an unusual and underrecognized pattern of lumbar disc herniation associated with pain and neurological deficit.Findings: Three patients presented with lower limb- and low back pain. MR imaging showed intracanalicular mass lesions with compression of the spinal cord and allowed precise localization of lesions in the extradural or intradural space. Diagnosis was straightforward for the patients with the posterior and anterior epidural disc fragments, whereas various differential diagnostic considerations were entertained for the patient with the intradural mass lesion. All patients underwent surgical removal of the sequestered disc fragments, and recovered full motosensory function. Surgical repair of the dura mater due to CSF leak was required for the patient with intradural disc herniation.Conclusion/clinical relevance: Posterior and anterior epidural, and intradural disc migration may manifest with clinical symptoms indistinguishable from those associated with non-sequestered lumbar disc hernias. Missed, migrated disc fragments can be implicated as a cause of low back pain, radiculopathy or cauda equina syndrome, especially in the absence of visible disc herniation. A high index of suspicion needs to be maintained in those cases with unexplained and persistent symptoms and/or no obvious disc herniation on MR images.